The URL can be used to link to this page

Home My WebLink AboutGW1--04183_Well Construction - GW1_20230706 i WELL CONSTRUCTION RECORD,, Q (GW-1) For Internal Use Only: 1.Well Contractor Information: / 1i1 k_i4j L l i _ha-A— ci I� .A.h• � .__ 14.WATER TOMS. Well ConnartorName FROM TO DFS(iiW lON 3 � �'G- A d ft lee ft: -14)47cV(,viLs� eAda n n. NC Wdl Contractor C,atffitationNmnber Q� p IS OUTER CASING(for mn>f wells)ORLIN=(d e . -7/Ve A (�L Gd , (X A FROM TOft. n DIAMETER MUCHNESS MATERIAL CompanyName J (y 16.INNER CASING OR TUBING(geothermal dt�d-[cop) 2.Well Construction Permit: A- / 9 -G I FROM TO DIAMETER ianorr E4y MATERIAL List all applicablefvdl construction permits P.m WC Camay.Stale.Variance.e ) '!-/ n- ft- la 5C/1%NJ /54/ 111 � 3.Well Use(cheek well use): 4 a n &ae ft Ai m' 5G/ ye l3j/'e___ Water Supply Welk 17.SCREEN FROM TO DMAti1E= SLATS= THICERF s MATERiAL ❑Agricultural ❑Mumcipal/Public $ taOn 'SG fin 40 3041 ss ❑Geothermal(Heating/Cooling Supply) .tlkgesidential Water Supply(single) n n fn. ❑lndustriallCommercial ❑Residential Water Supply(shared) is.GRODr r Mitigation ❑Wells>100.000 GPD FROM TO MATERIAL EMITACEMERTMETHOD&AMOUNT Non-Water Supply Welk 0 IL gi n d'O/e P/J5 pe-ze,1i [Monitoring ❑Recovery ft IL Injection Well: ft. It. ❑Aquifer Recharge ❑GmnndwatcrRemediation 19 SAND/GRAVEL PACK(if applicable) ❑Aquifer$triage and Recovery ❑Salinity Bather FROM TO MATERIAL EBEII3 IThTMEIROD °Aquifer Test ❑StormwaterDrainage 1-I ft &)oft- # 4/.1ril-ed /30z2-[_ ❑Experimental Technology . ❑Subsidence Control ft. ft. ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attack additional sheets ifne«aary) ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 1121 Remarks) FROM TO DES�IIOP(color,md�,mn/,.c>(ypar n size,era) 4.Date Weil(s)Completed: o(p/off al a3 Well ID# 24'/q 9! 6 a- a o n 5i9A,d/ ebtri Sa.Well Location: - o70 n by n C:• 4-s r 1-c-'i5 e 6-Awe/ • ePV5/TE14o'7)45 `o% I(o bit n '1- f )9A1i,.) G!ltel Fnelity/OwacrNnmc Faa141Dtl(tfapplicable) f 0?e54'5—i/e 0/ �A'c LE.SPe/Nnn< Vie, ft. - n , r--j;-- a`° °•, .4' f PhysitalAddress.CttS:andZlp II it. T.tin 1/4."B s r �: ,1,....:°' dlJoot?c 9 Goo-73 21 tEMARiS J1)L 0 € 2023 County Parcel Identification No.(PIN) 5b.Latitude and longitude i n;-l; r2 n?!�:.:,..r:,3 �r 1 in degrecs/minntes/seconds or decimal degrees: _, -r t.r ' .- (if well field,one lat/long is sufficient) 22.Certification: 3.5'°17'3,31" N 79° 32 ' 3S" • w 4a7 27,4 —! 13�F C - i2.�/�� • 6.Is(are)thewell(s): Eermanent or °Temporary Sigaabue of Certified Well Contractor Bysigrmrgthisfonn,I herebycerbfrthat the wells)was(were)constructed in accordance with 7.Is this a repair to an existing welt OYes or Aio ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consbvttmn Standards and that a copy If this tea repair,fill met)blown well omatmction information andexph&the nature ofthe afthis record has been provided to the well owns repairrmder02/rmtanCt sermon gran the bartoJthisjorm 23.Site diagram or additional well details 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Yon may use the back of this page to provide additional well construction info • construction,only 1 OW-1 is needed Indicate TOTAL of wells (add`See Over'in Remark Box).You may also attach additional pages if necessary. 24.SUBMHTTAL INSTRUCTIONS 9.Total well depth below land surface: • 4; 2 (a) Submit this GW-1 within 30 daysof well completionthe following:For multiple wells list all depths(fdifferert(example-3@200'and 2@100) P per 10.Static water level below top of casing: 3 O („) 24a. For AR Wells: Original form to Division of Water Resources (DWR), Ifwater level is above cam use'+_ Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617 11.Borehole diameter: 9 ((n) 24b.For Injection Wells Copy to DWR,Underground Injection Control(IUC) Program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction method: C kill/ZG� (i.e.auger.rotary,cable,lea pub,etc.) / 24c.For Water Supply and Open-Loop Geothermal Return Wells Copyto the county environmental health department oldie county where installed FOR WATER SUPPLY WEI.iS ONLY: 24d For Water Wells produdng over 100 1 I I GPD:Copy to DWR,CCPCUA Permit Program,1611 MSC,Raleigh,NC 27.99-1611 13a.Yield(gpm) 710 r p Method of test i/rll it 13In Disinfection type: L()i/I..,SR 7'�7, Amount 1/f6O?. • Form GW-1 North Carolina Department of Environmental Quality-Divis1OD°fWater Resources Revised 6-6-2018